Marie Manthey’s Nursing Salon

When I first posted about the overwhelming response to my blog, I left off the comments emailed me by Gary Saltus, a physician colleague. Gary specializes in helping  groups through transformational change and is working with CHCM create a program to build Physician/Nurse relationships.

It’s a shame I left Gary’s comments out because they are so vital to this discussion.

Here are the highlights of Gary’s email, followed by my original response (again):

I enjoy and appreciate your constant journey of discovering more and more in nursing and health care. I keep coming back to your primary statement of talking to the different people in health care because it’s something you want to do. I imagine this is your purpose in life at this time –your constant search for discovery, wherever it takes you. I imagine this is the lens you use to see the world: How do we do health care better?

I agree with you about the importance of conversation, but I look at it through my lens of transitioning with individuals, teams, groups, and organizations.

The challenge as I see it is to get the people involved to have these conversations with themselves first, to learn who they are and what their purpose/vision is. They need this self-knowledge so they have the self-permission to present who they are to the interpersonal environment (another individual, team, and group) with confidence.

Before the individual, team, group or organization can tackle the difficult and major issues that you present in you blog, they must go through orientation, differentiation with resultant cohesion conversation with each other first. These are the stages of maturation according to John Cater, PhD at the Gestalt Center for Organization & Systems Development. They also must go through these stages in three phases. Assimilation, differentiation, and manipulation. Each phase brings the system closer with the common denominator being trust. This process is how I facilitate working with groups. So the bottom line is we can’t start tackling the big issues until the system has matured. The dilemma is that organizations don’t think they have the time to let the Nurses/Physicians/Administrators do this group work.

I admire your passion and drive to facilitate change in the Nursing/Health Care arena. Our passions are in attunement. Thanks for including me in your thoughts. I look forward to talking to you in the future about our passions and shared visions.

Gary, thanks so much for your thoughtful and insightful comments. I don’t have the grasp on gestalt that you do…but I definitely get the ‘gist’ of what you are saying. I agree that the transformation has to start with the individual, and then move to groups and teams and that the employing institutions do not yet see the benefit of this kind of staff development.

Throughout my career I’ve been fascinated by how attitudes/behaviors of employees change as institutional and leader values change. I’ve seen so many dramatic changes (both positive and negative) in the lives of patients and nurses that I feel compelled to continue working with these issues. The issue of no time to engage in these discussions is really daunting. Also, the separation between professional cultures has erected many barriers to communication I am beginning to see coming down. Another thing that I find very interesting is that the barriers between nurse educators and practice nurses are also beginning to crack. Real light is beginning to shine through. One of the ways I get to see this is thru the monthly Nursing Salons which I have been doing at my home for the past five years. Attendees vary according to the email lists interests in coming on that evening. It is sort of a blend of the Open Space technology and Socrates Cafe conversation format. I have so enjoyed seeing nurse educators and nurse managers, staff nurses, alternative therapy nurses, public health nurses, etc all sitting around talking about some issue or another in nursing. A retired physician comes whenever he can. And you are right…..it really is about improving Health Care.

M. B., a nurse from Alberta emailed me with some comments about professionalism:

I highly value the principles of professionalism but find in some workplaces and amongst some nursing colleagues that this has varying connotations and meanings. I have put this question to various professionals in health care and some exclaim that it does not truly exist. The more I search I have come to realize that professionalism in an institution is largely dependent on leadership’s belief and value of professionalism.

The extent of the leadership’s belief is reflected in how professionalism is exercised and maintained in culture of that work environment. If this belief is low, then any kind of behavior is acceptable in that work environment. If it is high, then that the culture will be of mutual respect and high trust. This indeed would be the ideal workplace but I am afraid I have been exposed to both in my life time career, thus far. The first is “hell”, the second is “heaven”.

I was very confused about the meaning of “professionalism” for a long time as well. Then I was taught about the definition used by sociologists, particularly the professionals use of autonomous decision making. I think our lack of clarity about what decisions we can rightly make (despite the clarity of language in the license) leads to the ambiguity that exists at all levels

So, first of all, there is the matter of professional practice. And then the matter of professional behavior. I find it useful to concentrate on the first: professional practice. This is where, as my friend from Alberta notes, leadership is critical. If the CEO, COO, CNO, CFO — the top leaders of the hospital — do not accept the notion that nursing is a profession with decision-making authority, they will not trust nurses.

This lack of trust creates a workplace environment that is antithetical to the normal risk-taking of decision-making. This lack of trust in employees sets up structures and behaviors that result in negative interpersonal relations. Nevertheless, I have seen many examples of creative and courageous leaders (below the level of the “Os”) who have been able to create healthy unit or departmental level cultures in spite of a lack of support from the highest level.

I know these statements are a simplification of highly complex factors, but trust is one of the major reasons some hospitals are heaven for employees, while others are hell. Couldn’t agree more. Like many of us, M. B. is looking for ways to build up professional nursing:

I am looking for more tools, any works that are currently out there to share with others to move nursing in this direction.

Creative Health Care Management has some 3-day programs that can transform nurses and their practice. One is called Leading an Empowered Organization and is for unit and departmental leaders and managers.  The other two are Leadership at the Point of Care and Reigniting the Spirit of Caring, both for clinical care-givers. All three are set up so we can ‘train-the trainers’ and license the programs for use by associations, large systems, and individual hospitals

M. B. speaks for so many of us when she ends with:

I believe nursing is an honored and privileged profession/family to belong to.

Recently a graduate student in nursing asked if she could interview me for an assignment on Leadership. As I answered her questions …”when did you first know you were a leader?”, “where did you learn how to be a leader?” “what is the most important thing you learned?” … I was led into some

Recently a graduate student in nursing asked if she could interview me for an assignment on Leadership.   As I answered her questions …”when did you first know you were a leader?”, “where did you learn how to be a leader?” “what is the most important thing you learned?” … I was led into some insightful reflections about change I’d like to share with you. I hope the readers will share their own insights as we ‘blog-on’ together.

First of all, when Primary Nursing was originally implemented, I knew nothing about change.   If I had, Primary Nursing might not have started when it did.  We were trying to do something else, called Unit Management.   A few roadblocks along the way led us to change directions dramatically, with the result that the staff of real unit actually implemented the delivery system before we knew they were changing delivery systems. They didn’t know it either…none of us understood the profound change the staff was creating as they moved from traditional team nursing into what we eventually called Primary Nursing.

I didn’t know about PERT charts and force field analysis….or about how to deal with resistance, or any of the theories commonly taught as part of the change process. Therefore, we didn’t have steps outlined, with time tables, goals, benchmarks, etc…. and were thus free to support the staff throughout this period of change.  All we had to guide us was common sense.

Which leads to the first learning. Decentralized Decision-Making is the core of Primary Nursing.   As I came to understand how this organizing principle works, I eventually constructed the following equation:   Change:Empowerment = Empowerment:Change.  This equation is founded on the truth that the people who know the most about the work being done are the people doing the work. Therefore, their knowledge needs to be used in deciding how to improve the work.

What role does that leave Leaders?   And how can Leaders get people to agree on how to improve their own work?

The second learning has to do with the use of visioning and inspiration as leadership tools.  One of the most important roles of a leader is to be able to paint a picture of a foreseeable future that is more desirable than the present, in language that inspires others to follow.  A ‘good’ leader will base this vision on values that are positive universal human values.

And the third learning has to do with infrastructure. A good change project (one that is successful) will incorporate a structural design that provides clear roles/expectations for appropriate decision-making at the various levels of authority. The design of the structure must be carefully thought-out……be based on the current role responsibilities throughout the department/institution with decision-making carefully allocated to the appropriate authority levels.

Those of you who have read Relationship Based Care: A Model for Transforming Practice will recognize in the above paragraph two of the four elements of Jayne Felgen’s theory of change…..Inspiration, Infrastructure, Education and Evidence.   Our extended experience with operational change will hopefully extend educational realms.